A collection of papers published in a recent issue of Social Science and Medicine considered the implications of the recent crisis in the financial sector and subsequent austerity policies for population health. The conclusions were equivocal. On the one hand the direct impact of the financial crisis (e.g. unemployment) on health is clearly detrimental to the individual concerned and their immediate family. For instance, the incidence of suicide, drug abuse and domestic violence might be expected to rise.

Yet at the same time economic downturns may lead to an improvement in the overall health of populations. But what explains this apparent contradiction? One possibility is that population health may be enhanced during periods of economic downturn because of a reduction in unhealthy ‘affluent behaviours’ such as the over consumption of food and alcohol or a fall in road traffic accidents. What is clear is that the longer term implications of the recent financial crisis are difficult to predict.

Geography matters

An important omission from this discussion of the health implications of the financial crisis is a consideration of geography. This seems surprising as the health consequences of economic retrenchment are unlikely to be evenly shared across all parts of the country. In the UK for example, the financial crisis and subsequent austerity are likely to affect people living in Glasgow rather differently to folks from London. The health impacts will be most detrimental for people in the least socially advantaged places. It is feasible that in the most prosperous regions of the country, health will be unaffected…..or even enhanced. In short, geographical inequalities in health in the UK could rise substantially in response to the ‘austerity agenda’.

Financial crisis & geographical inequalities in health

So what are the processes linked to the deficit reduction strategies that are likely to affect geographical inequalities in health in the UK? In this CRESH blog we outline four (non-exhaustive and inter-related) reasons for why we might expect health to become geographically polarised.

Perhaps most obviously, the ‘social geography’ of the UK is likely to be heavily affected by the current and forthcoming austerity strategies which in turn can be expected to undermine some key social determinants of health. Austerity measures could well widen the geographical discrepancy in social markers at various different scales, particularly between regions of the country. For example, places with a larger proportion of workers employed in the public sector will be particularly vulnerable to unemployment and job insecurity. Similarly income disparities between regions are likely to grow. Unemployment, job insecurity and income inequality are causally related to health. One response to the changing socio-economic map of the UK is likely to be heightened regional inequalities in health.

Job insecurity, unemployment and changes to welfare including a cap on housing benefits are likely to ‘disrupt’ patterns of mobility and lead to new forms of migration and mobility streams that are health selective. As job markets stagnate or contract, it is feasible that migration from north to south may lessen and/or become increasingly socially selective. There is also the worrying prospect of low income (and less ‘healthy’) families being displaced from their homes by the cap on housing benefits. This policy change is likely to see a movement of low income (and less ‘healthy’) individuals away from more prosperous suburbs into more ‘affordable’ neighbourhoods, as well as the entrapment of others in less healthy places.

Austerity measures are already leading to a reprioritisation of public services provided by local authorities and other organisations. Which services will continue to receive resources and where there will be disinvestment is starting to become clear. As a recent blog argues, the middle classes are skilled in resisting cuts in services and new (unwanted) developments, an advantage that may lead to further disinvestment in disadvantaged communities during periods of fiscal tightening. At the same time, the Westminster government is looking to deregulate various environmental regulations that were often implemented to protect vulnerable communities from the health effects of various types if disamenities. The re-prioritisation of investment in public services and changes to environmental legislation is likely to lead to greater environmental disparities across regions in the UK. Environments that support health and well-being may well become just as disparate, raising environmental justice concerns and negatively affecting area-level health inequalities.

Much academic research and policy initiatives have been concerned with ‘place-based’ determinants of health. The premise here is that factors relating to geographical (often local) context are fundamental to understanding social and geographical differences in health outcomes and behaviours. Place-based factors such as neighbourhood social capital, local norms, access to shops and services, social networks, concentration of poverty and a whole host of other factors have been implicated. Austerity measures are likely to undermine efforts to improve local infrastructure (see above) as well as disrupt local community networks. Similarly, earlier CRESH work suggests that ‘problem’ health behaviours such as smoking, drinking and gambling may be reinforced in disadvantaged settings during tightened financial times.

We would be delighted to hear your comments and suggestions. What are other mechanisms that might affect geographical inequalities in health? What are the key concerns outside the UK?

This is really fascinating, and incredibly important to think through. I suspected that connected with some of the points you have made here is the potential for deletarious reassessment of risk in a time of recession. Policies or actions that localities or other scales of government may not have considered as viable in the past now become justifiable in the context of financial shortfalls. Both governments and citizens might be more willing to accept ‘bad’ jobs, or those that pose greater risk to multiple factors of wellbeing, with the justification that these are better than no jobs. Whether this is taking place at the scale of a household or a council, what is ‘too risky’ or undesirable changes. I don’t know if this is happening across the UK, but I have seen it reflected in the lives of some of the young people who I’ve worked with. Many of them don’t want to do rather dangerous, unskilled, part-time temporary manual labour (or engage in even more dangerous informal economies). But it is the only thing available to them, and when compared with unemployment, it is the preferred option.

I also wonder about shifts in employment health and safety regulations in this context, and if the kind of geographies of production might be revealed in certain kinds of health effects. Globally we know that the burden of tight purses and higher quotas often falls upon the shoulders of those labouring on the production line or in the fields. In some cases, this is driven by formal policies reducing the rights of workers to not be harmed by their labour. In other cases, it happens through informal lack of oversight. In the latter, some places fall outside of existing regulative infrastructure much more easily than others.

I know very little about how the tracking of health data works (!), but I also wonder if it will be easy to identify what I would think of as the layering-up of negative health consequences? I’m thinking of people with disabilities, for instance, who are being disproportionately hit by the austerity measures in the UK, but for whom shifts in health may be less evident, or at least less accounted for.